Fillable Form C-1am - Amended Status Report printable pdf download

Amended Status Report

Mail To:

This form can be completed online at

Cashier - Texas Workforce Commission

P.O. Box 149037

Austin, TX 78714-9037

This report is to update your account with TWC

512.463.2731

*Indicates required information.

Identification Section

*1. Account Number assigned by TWC

*5. Federal Employer ID Number

*2. Name

*6. Area Code/Phone Number

*3. Mailing address

*7. Address where payroll records are kept

*4. City, State, Zip

*8. City, State, Zip where payroll records are kept

*9. Owners or Officers

Name

Soc. Sec. No.

Title

Residence Address, City, State

10. Business locations in Texas

Trade Name

Street Address, City

Kind of Business

No. Employees

Acquisition Section

11. If you acquired the business in Texas from a previous owner, you must complete Items 11-13.

If a partial acquisition, the predecessor/successor may jointly submit an application for partial transfer of experience.

a. Acquisition Date :

Month

Day

Year

b. Previous Owner’s TWC Account Number (if known):

c. Previous Owner’s Name:

d. Previous Owner’s Address:

e. City, State, Zip:

f. Portion of business acquired:

(check one):

All

Part (specify which part of business was purchased)

12. On the date of the acquisition, was the previous owner(s), or any partner(s), officer(s), shareholder(s), other owner(s) or a person elated by blood or marriage to any

of these individuals, holding a legal or equitable interest in the predecessor business, also an owner, partner, officer, shareholder, or other owner of a legal or equitable

interest in the successor business?

Yes

If “Yes”, check all that apply:

Same owner, officer, partner, or shareholder

Same parent company

Sole proprietor incorporating

Other if other, please describe______________________________________________________________________________________

If “No”, on the date of the acquisition, did the previous owner(s), partner(s), officer(s), shareholder(s), other owner(s) or a person elated by blood or marriage to any of

these individuals, holding a legal or equitable interest in the predecessor business, hold an option to purchase such an interest in the successor business?

Yes

13. After the acquisition, did the predecessor continue to:

•

Own or manage the organization that conducts the organization, trade or business?

•

Own or manage the assets necessary to conduct the organization, trade or business?

•

Control through security or lease arrangement, the assets necessary to conduct the organization, trade or business?

•

Direct the internal affairs or conduct of the organization, trade or business?

Yes

If “Yes" to any of above, describe: